Form 114 "Request for Payment for Services or Reimbursement for Compensable Expenses" - Kentucky

What Is Form 114?

This is a legal form that was released by the Kentucky Department of Workers' Claims - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Kentucky Department of Workers' Claims;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 114 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Workers' Claims.

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Download Form 114 "Request for Payment for Services or Reimbursement for Compensable Expenses" - Kentucky

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KENTUCKY DEPARTMENT OF WORKERS CLAIMS
Form 114
Frankfort, Kentucky 40601
REQUEST FOR PAYMENT FOR SERVICES OR REIMBURSEMENT
FOR COMPENSABLE EXPENSES
TO BE FILED WITH THE RESPONSIBLE EMPLOYER OR ITS PAYMENT OBLIGOR
â Name, address and Workers Compensation claim number of Employee for whom services were
provided or expenses incurred:
____________________________________________________________________________________________
____________________________________________________________________________________________
ã Specific type and dates of service(s) provided:
Date(s)
Type of Service(s)
ä Name and address of physician who ordered services: (include written authorization if available)
____________________________________________________________________________________________
å Reasonable value of services, including method of computation:
$_______________: _____________
____________________________________________________________________________________________
æ Other expenses incurred for cure or relief of a work injury or occupational disease(s):
Date
Description of Expense(s)
$ Amount
If mileage, no. of miles
- - - - - - -
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Total
$:
Miles:
Please attach receipts for all purchased items.
Certification:
I hereby certify that the above services were performed or expenses were incurred for the cure or
relief of a work injury or occupational disease sustained by the above employee.
Witness: ___________________________
_________________________________________
(Name of Person requesting payment)
Date: _______________________________
Address: __________________________________________
Phone no: _________________________________________
NOTICE:
Any person who knowingly and with intent to defraud any insurance company or other person files a
statement or claim containing any materially false information or conceals, for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
KENTUCKY DEPARTMENT OF WORKERS CLAIMS
Form 114
Frankfort, Kentucky 40601
REQUEST FOR PAYMENT FOR SERVICES OR REIMBURSEMENT
FOR COMPENSABLE EXPENSES
TO BE FILED WITH THE RESPONSIBLE EMPLOYER OR ITS PAYMENT OBLIGOR
â Name, address and Workers Compensation claim number of Employee for whom services were
provided or expenses incurred:
____________________________________________________________________________________________
____________________________________________________________________________________________
ã Specific type and dates of service(s) provided:
Date(s)
Type of Service(s)
ä Name and address of physician who ordered services: (include written authorization if available)
____________________________________________________________________________________________
å Reasonable value of services, including method of computation:
$_______________: _____________
____________________________________________________________________________________________
æ Other expenses incurred for cure or relief of a work injury or occupational disease(s):
Date
Description of Expense(s)
$ Amount
If mileage, no. of miles
- - - - - - -
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Total
$:
Miles:
Please attach receipts for all purchased items.
Certification:
I hereby certify that the above services were performed or expenses were incurred for the cure or
relief of a work injury or occupational disease sustained by the above employee.
Witness: ___________________________
_________________________________________
(Name of Person requesting payment)
Date: _______________________________
Address: __________________________________________
Phone no: _________________________________________
NOTICE:
Any person who knowingly and with intent to defraud any insurance company or other person files a
statement or claim containing any materially false information or conceals, for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.